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Atlas / NTSB / DEN89FA064

NTSB CAROL · Event

Event DEN89FA064

1989-01-20 BUENA VISTA, Colorado, United States Minor 1 aircraft Status: Completed

Aircraft involved

Probable cause & findings

INADVERTENT DEACTIVATION OF FUEL TO THE LEFT ENGINE AS THE PILOT WAS MAKING A PRECAUTIONARY SHUTDOWN OF THE RIGHT ENGINE, AND HIS FAILURE TO FOLLOW THE EMERGENCY CHECKLIST PROCEDURE. RELATED FACTORS WERE: LOW GEARBOX OIL PRESSURE (AT FLIGHT ALTITUDE), AND UNEVEN TERRAIN THAT WAS ENCOUNTERED DURING THE EMERGENCY LANDING.

Factual narrative

DRG FLT, CREW SHTDN RGT ENG WHEN WARNING LGT FOR GEARBOX OIL PRES ILLUMINATED & PRES WAS NOTED BLO MIN LMT OF 130 PSI. SHORTLY AFTER SECURING RGT ENG, L ENG LOST PWR. (FUEL TANK SHUTOFF VLV SWS & FUEL X-FEED VLV SW WERE LCTD NR EACH OTR.) ATMTS TO RESTART L ENG WERE UNSUCCESSFUL. WITH LACK OF AC ELEC PWR, CAPT COULD NOT UNFEATHER RGT ENG FOR RESTART. DRG EMERG LNDG, ACFT WAS DMGD ON UNEVEN TRRN. OPNL CHECK OF RGT ENG (AT GND LVL) REVEALED NO MALFUNCTION THAT WOULD HAVE PREVENTED NML OPN. EXAM OF L ENG REVEALED TURBINE SECTION HAD OVERHEATED & TURBINE BLADES HAD SEVERE HEAT DMG. CAPT SAIDTHAT WHEN HE TRIED TO RESTART L ENG, FUEL VLVS WERE IN NORMAL PSN & PWR LEVER WAS 1' ABV IDLE. HE RECALLED AN ENG RPM OF8000, BUT DIDN'T RECALL IF HE HAD USED FEATHER BUTTON TO REDUCE RPM TO 3000 (AS DRCTD BY CHECKLIST). HE VERIFIED FUEL SWS WERE 'ON' & HE TRIED TO X-FEED FUEL (IN EVENT OF BLOCKAGE). X-FEEDING OF FUEL WAS NOT PART OF RESTART PROC. FLT MAN-UAL CAUTIONED ABT IMPORTANCE OF REDUCING PWR TO FLT IDLE, TO DECREASE FUEL FLOW TO ENG & MINIMIZE POSSIBLE OVERHEATING. Source: NTSB Aviation Accident Database (Pre-2008 Archive) Retrieved: 2026-02-12

Verbatim from NTSB's published report. Source file NTSB_1989_DEN89FA064.txt. Findings + structured fields enriched from FAA avall.mdb. Full investigation docket on data.ntsb.gov ↗.